VBS Registration

 
 
June 5th-9th
3 Years Old-Completed 5th Grade
 
 

Child's First Name (required)

Child's Last Name (required)

Parent's Name (required)

Your Email (required)

Phone Number (required)

Emergency Contact Name (required)

Emergency Contact Phone Number (required)

Child's Age (required)

Child's Completed Grade (required)

Does your child have any special needs, medical challenges, learning differences, or dietary restrictions? If so, Please List Below

Allergies (if any)

Any additional information you would like to provide

Medical Release (required)
I hereby consent to my participation or my child's participation in the above event and other events of scheduled activities either at or sponsored by First Baptist Church of Lilburn ("FBCL") and agree to assume all of the risks related to such participation. I understand that participation in athletic activities sponsored by FBCL involves the risk of injury.
I authorize a representative of FBCL to contact medical personnel to perform x-rays, tests, or perform or provide other medical treatment deemed necessary or desirable for my care or my child's care. I give permission for administration of medication, injections, and/or anesthesia and/or surgery if deemed necessary or desirable by medical personnel for my care or my child's care. I also authorize the release of the above information to assist with their decisions for my care or my child's care
I release, hold harmless, and covenant not to sue, First Baptist Church of Lilburn, its agents, and employees from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury or associated medical care administered to me or my child during and/or relating to or arising out of participation in this event or other events and activities either at or sponsored by FBCL.
YesNo

Photo Release (required)
I give permission for myself and/or my child to be photographed or videoed during the above event and other events and activities either at or sponsored by FBCL. I also grant FBCL permission to publish and/or share my/my child's name, picture, portrait, video, and/or photograph in all forms and media and in all manners, for display, publication, advertising, promotions, websites, and any other lawful purposes, taken of children and adults during this event, on FBCL website and/or other FBCL publications/media. I waive any right that I may have to inspect and/or approve the finished product(s) and I release, hold harmless, and covenant not to sue, First Baptist Church of Lilburn, its agents, and employees from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to me and/or my child related to the publication and/or sharing of the name, picture, portrait, video, and/or photograph.
YesNo

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